GW1--05969_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: VZ
1.Well Contractor Information: �y )/
Pr�eo �eI fDV�L-!(� 14.:WATERZONES . 1 .__
Well ntractorName _ FROM TO DESCRIPTION
C LP <a -A 3 ti'et• Yee. atr6,1l
ft: ft.
NC Well Contractor Certification Number
welt nn JJ IS•OUTERCASING(formulti-casedwells),OR.LINER`(tfaplicable)
•r .'(S (2/?cJ/' '1v � C1.C. FROM TO DIAMETER® / fL; 9S• ft in. �D7; a1 ��
HICKNESS MATERIAL
Co..r., Name ;�16;,INNER:CASINGORTUBING(tgeotti�mat:clased-loop) :� � __,_
t7 2.Well Construction Permit#: �� FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN =., . - -
'v
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
Agricultural DMunicipal/Public ft ft. Iin'.
Geothermal(Heating/Cooling Supply) Bresidential Water Supply(single) ft rt. lin.
Industrial/Commercial 'QResidential Water Supply(sherd)
'ption FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W_ell: it ft �
d a� hill 1 Pint_ !14ErPe
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
.„;19:SAND/GRAVEL PACK(if applicable)' =
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ED Stonnwater Drainage ft. ft.
Experimental Technology DiSubsidence Control ft. ft. `
Geothermal(Closed Loop) Tracer -20.DRILLINGLOG(attach additional sheets if.ner wary):,.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)6. FROM TO DESCRIPTION(tutor,badness,sail/rock type,grain else err:)
a ft 75. ' .eedr/ey
4.Date Well(s)Completed: ��^� Well ID# ,S ft. '75 ft. i 6"' i�''y_
5a.Well Location: 9S ft .cos ft. 0.�N, ,e__
Dope >ea/Al/y 3Q /v4 s is . ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1'' -..e• `:-,t ra 1 T`"
g9V/ Can u•t�xae 4i�i'e.c ft. ft �. ..�w..: .. ,� �° .
Physical Address,City,and Zip ft ft. 09 (u 24
GoOrl 3.r'/-/'t; 'yg 21.REMARKS l " -
y County Parcel Identification No.(PIN) fm::,`'l i'n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilon is sufficient) i .4l-
3 Sr1s9.? e$' N I.
G ‘gs77 w 22.Certification: a col �;•
•
• 6.Is(are)the well(s) Permanent -or- Temporary - of Certified Well Contractor Date
� By signing this form,I hereby certt&that the well(s)was(were)constructed-in accordance
7.Is this a repair to an existing well: Dyes or La"< with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. -
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l 0 5" (t) 24a. For Mi Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2 a@100') construction to the following:
10.Static water level below top of casing: 65. (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t� I
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: nth construction to the following: '
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ® Method of test: 'CZ c)i. Lr ra,-- 24c.for Water Supply&Infection Wells: In addition to sending the form to
L ` the address(es) above, also submit'one copy of-this form within 30 days of
13b.Disinfection type �t Amount: �/ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016